Mental Health Service Request Form
Please allow up to 72 hours for a member of our team to process your request. Filling out this request will put you on our rotation to see a provider. Provider availability may vary. Please note that this request does not put you into direct contact with a mental health provider. For immediate medical concerns please call 911. For mental health crisis intervention in Atlantic County, please call 609-344-1118.
Name
*
First Name
Last Name
Date of Birth
*
Please select a day
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Day
Please select a month
January
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December
Month
Please select a year
2024
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Year
Age
Gender
*
Please Select
Male
Female
Transgender Male
Transgender Female
Non-Binary
Agender
Prefer not to state
Phone Number
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Parent/Guardian (if client is under 18)
First Name
Last Name
Payer Information
*
Please Select
Insurance
Self Pay
EAP
Insurance Name
*
Please Select
N/A
Horizon
Cigna
Aetna
Medicaid
Medicare
AmeriHealth
Humana/Tricare
Optium
United Health
Meritan Health
Mental Health Consultants
Magellan
Member ID#
*
How did you hear about us?
Please Select
Online
Family/Friend
Professional Provider
Self Referral
Type of Services Requested
*
Individual Therapy
Family Therapy
Couples Therapy
Group Therapy
Psychiatric Services/Medication Monitoring
Other
Elaborate Reasons for Requesting Services:
*
Provider Demographic Preference (Gender, Race, etc)
*Disclaimer- More specific requests may result in a longer wait for for a provider*
Does Someone you know Obtain Services from us?
No
Yes
Submit
Should be Empty: